Tourniquet use in total knee arthroplasty and the risk of infection: a meta-analysis of randomised controlled trials

Abstract

Purpose The intra-operative use of tourniquets during Total Knee Arthroplasty (TKA) is common practice. The advantages of tourniquet use include decreased operating time and the creation of a bloodless visualisation field. However, tourniquet use has recently been linked with increased post-operative pain, reduced range of motion, and slower functional recovery. Importantly, there is limited evidence of the effect of tourniquet use on infection risk. The purpose of this systematic review and meta-analysis is to fill this gap in the literature by synthesising data pertaining to the association between tourniquet use and infection risk in TKA. Methods A systematic literature search was performed on Pubmed, Embase, Cochrane and clinicaltrials.gov up to May 2021. Randomized control trials were included, comparing TKA outcomes with and without tourniquet use. The primary outcome was overall infection rate. Secondary outcomes included superficial and deep infection, skin necrosis, skin blistering, DVT rate, and transfusion rate. Results 14 RCTs with 1329 patients were included. The pooled incidence of infection in the tourniquet group (4.0%, 95% CI = 2.7–5.4) was significantly higher compared to the non-tourniquet group (2.0%, 95% CI = 1.1–3.1) with an OR of 1.9 (95% CI = 1.1–3.76, p = 0.03). The length of hospital stay, haemoglobin drop (0.33 95% CI =0.12–0.54), P = 0.002) and transfusion rates (OR of 2.7, 95%CI = 1.4–5.3, P = < 0.01) were higher in the tourniquet group than the non-tourniquet group. The difference in the length of inhospital stay was 0.24 days favouring the non-tourniquet group (95% CI = 0.10–0.38, P = < 0.01). The incidence of skin blistering (OR 2.6, 95% CI = 0.7–9.9, p = 0.17), skin necrosis (OR 3.0, 95% CI = 0.50–19.3, p = 0.25), and DVT rates (OR 1.5, 95% CI = 0.60–3.60, p = 0.36) did not differ between the two groups. Conclusion Quantitative synthesis of the data suggested tourniquet use was associated with an increased overall risk of infection, intraoperative blood loss, need for blood transfusion and longer hospital stay. Findings of this meta-analysis do not support the routine use of tourniquet in TKA and arthroplasty surgeons should consider any potential additional risks associated with its use. Level of evidence meta-analysis, Level II.

Knowledge, attitudes, and practices of orthopedic operating room personnel regarding the use of pneumatic tourniquets

“…Previous studies have reported that attitudes of orthopedic surgeons towards using PTs to prepare the operating field are mixed, with many concerns related to the higher risk of infection and longer hospital stay [ 24 , 25 ]. This study included a wider range of medical personnel, such as orthopedic nurses (31.5%) or operating room nurses (19.9%), and, most likely because of that, attitudes were predominantly positive.…”

Change in organism between first- and second-stage revision for periprosthetic joint infection of knee arthroplasty independently associated with increased risk of failure

“…Documentation on the use of interim antimicrobials was often lacking, such as the type of antibiotics given, the length of the course, and the route of administration, as well as details of the antibiotics loaded into the cement spacers, so these was not included in the final analysis. There was also variable documentation of the use of intraoperative tourniquet, so despite its previously recorded association with an increased risk of infection, 29 this was not included in the final data set. The retrospective nature design, however, meant that the data recorded in real time was done so without bias and with no influence from the current study.…”

Ankle-Angle-Adjusting Fibular Osteotomy in Closed Wedge High Tibial Osteotomy

“…These strict bleeding-control procedures help to minimize postoperative swelling due to hemorrhage, without an indwelling drain ( Table 2 ). As for OWHTO 10 or TKA, 11 the safe nontourniquet procedure may decrease the intraoperative/perioperative risks of complications such as bleeding, hematoma, or infection and may enhance postoperative recovery.…”